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Doctor Name
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Last
Order Date
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Phone Number
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Patient Name
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First
Last
Patient
Male
Female
Email
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Age
DUE DATE
By 5:00 PM
By 5:00 PM
Please do not schedule appointments on delivery date.
Type of Restoration
LAVA
PFM
eMax
Zirconia (HIZ360)
Layered Zirconia
FMC (Economy)
Implant
FMC (High Noble)
PFM Metal
Non Precious
Semi Precious
Precious Yellow Gold
Precious White Gold
Repair / Remake
Repair
Remake
Tooth Number(s)
SHADE
Occlusal Stain
None
Medium
Dark
Light
Anterior
No Metal Showing
Lingual Band
Metal Lingual/ Metal Contact
Metal Lingual/ Porc. Contact
Posterior
Lingual Band
Metal occlusal excluding buccal cusp
Metal occlusal including buccal cusp
Pontic Design
Hygienic
Modified Ridge
Bullet
Ridge Lap
Margins
Metals
Show no Metals
Porcelain
Occlusal
In Occlusal
Out Of Occlusal
Foil Relief
Special
Call
Return for Die Trim
Metal Frame Try-In
Description
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D.D.S License No:
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TERMS:All accounts are payable within 25 days of statement date. Delinquent accounts will be subject to COD status and a late charge of 3% compound interest per month on the unpaid balance
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